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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320265
Report Date: 06/13/2025
Date Signed: 06/13/2025 05:17:51 PM

Document Has Been Signed on 06/13/2025 05:17 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:PEACH HOSPITALITY ADULT RESIDENTIAL CAREFACILITY NUMBER:
198320265
ADMINISTRATOR/
DIRECTOR:		JOHNSON, TUNISIAFACILITY TYPE:
735
ADDRESS:3501 W. 118TH STREETTELEPHONE:
(310) 978-8886
CITY:INGLEWOODSTATE: CAZIP CODE:
90303
CAPACITY: 6CENSUS: 2DATE:
06/13/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:30 AM
MET WITH:Tunisia JohnsonTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced Case Management - Annual Continuation Visit to complete the Required 1-Year Annual Visit dated 05/30/2025, with the primary focus on Infection Control measures and using the new CARE Inspection Tool. Upon arrival at the facility, LPA Bunker conducted a risk assessment. Based on the evaluation, the facility is clear of COVID-19 infection. LPA was properly screened for COVID-19 symptoms and LPA temperature was checked. LPA Bunker met with Licensee/Administrator Tunisia Johnson and explained the purpose of today's Annual Inspection. LPA verified that the facility has an approved Mitigation Plan Report and Infection Control Plan. There are currently two (2), Westside Regional Center Adult Residential Care Facility (ARF) consumers in placement. The facility's annual fees are current.

The following 12 Domains will be observed and reviewed: Infection Control, Physical Plant & Environmental Safety, Operational Requirements, Staffing, Personnel Records-Training, Client Rights-Information, Client Records-Incident Reports, Food Service, Health-Related Services, Incidental Medical Services, Disaster Preparedness, and Emergency Intervention. "LPA Bunker will be using this tool and methods that have been developed to improve the efficiency and accuracy of the Department of Social Services' facility inspections."

See continued LIC809-C page 2
NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Pamela Bunker
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: PEACH HOSPITALITY ADULT RESIDENTIAL CARE
FACILITY NUMBER: 198320265
VISIT DATE: 06/13/2025
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Continued LIC809-C page #2

The facility is a single-story-family home located in a residential neighborhood. Licensee Ms. Johnson and LPA Bunker toured the facility which consisted of the following: Living room, dining room, kitchen, 3 bedrooms, 1 bathroom, laundry room, shaded area, indoor/outdoor activity areas, and detached garage. The front and backyard landscape was in good condition at the time of the visit.

During the tour, LPA observed the facility’s infection control practices. LPA observed sanitizer, visitor log, and thermometer at the facility entrance. Logs of daily COVID-19 screening and temperature checks of clients and staff were available and updated. PPE supplies are readily available to staff, and an additional supply of PPE was observed. Sufficient liquid soap, paper goods, cleaning, and disinfecting supplies were observed.

Documents were posted as mandated on the bulletin board wall in the dining and laundry rooms. The following Title 22 regulated areas were audited and found to be in compliance: Bedrooms contain the required furniture. The client’s bedrooms were inspected for safety, privacy, and comfort. The living areas are clean, and the bathrooms are both clean and operational. The first aid kit is fully stocked with a manual, the hot water temperature was measured at 117 degrees Fahrenheit, the telephones are working, smoke and carbon monoxide detectors were in compliance, fire extinguishers are fully charged, medications were centrally stored and properly locked in a file cabinet in the laundry room, and records are current, ample supply of perishable and nonperishable food, adequate linen supply, fire/emergency drill conducted on No firearms on the premises, the client's bedroom windows had no sliding window lock with thumbscrew, all exit doors were in compliance, covered trash cans, and no bodies of water were present. Hazardous items are inaccessible to clients, and the yard is free of debris and hazards. Licensee Ms. Johnson states staff was given training on dependent adult and elder abuse reporting.

There were no deficiencies cited. LPA Bunker provided Licensee/Administrator Tunisia Johnson with copies of the LIC809 and LIC809-C documents.

Exit interview conducted.
NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Pamela Bunker
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2025
LIC809 (FAS) - (06/04)
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